Correct Coding to Maximize Reimbursements: Common Urological Coding and Billing Errors. Michael A. Ferragamo, MD, FACS
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1 Correct Coding to Maximize Reimbursements: Common Urological Coding and Billing Errors Michael A. Ferragamo, MD, FACS Coding and Reimbursement Consultant; Assistant Clinical Professor of Urology, University Hospital, State University of New York; Stony Brook, New York Objectives: Determine accurate from inaccurate urological coding Recognize common urological coding errors and avoid loss of entitled payments Maintain coding rules compliance
2 6 th Annual Excellence in Urology Seminar Canyons Ski Resort, Park City, Utah February 5 8, 2014 Common Urological Coding and Billing Errors Michael A. Ferragamo MD, FACS Assistant Clinical Professor of Urology State University of New York University Hospital and Medical College Stony Brook, New York Editor: Urology Coding Alert, Naples, Fla.
3 Common Coding Errors in Urology Use of modifier 25 Use of modifier 59 Treatment of bladder neck contracture Complicated catheterization Bladder biopsy vs TURB Removal and closure of skin lesions
4 Modifier Confusion 25 76
5 Modifier Errors in Urology E/M + Modifier 25 + Cystoscopy Modifier 25 Significant, separately, identifiable E/M service by the same urologist on the Same Day of the procedure or other services The E/M services may be prompted by the symptom for which the procedure or service was provided. Can only be used on the day of a minor procedure Attached to an E/M code Do not report an E/M service that resulted in a decision to perform minor surgery OIG: Incorrectly used on 35% of claims CMS: > $538 million in improper payments 2013 CPT, current procedural terminology, Appendix A page 595
6 Modifier Errors in Urology * Modifier 25* Use with 0 or 10 day global procedures Examples of correct use: Two co existing unrelated problems (with separate diagnoses) Problem prompts E/M service and a procedure (may use the same diagnosis) Same day counseling after surgery No effect on payment 2014 CPT, Current Procedural Terminology, Appendix A, page 645
7 Coding Tips Modifier 25 Errors Do not bill an E/M service: The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure, and an examination that includes the decision to do minor surgery should not be reported as an E/M service. Bill an E/M service if a urologist performs a medically reasonable and necessary full urological examination at the same encounter when performing a minor surgical procedure NCCI Manual: Chapter 1
8 Coding Tips Modifier 25 for Medicare Per Medicare Claims Processing Manual (100 04) Section 40.1 (C) Minor Surgeries and Endoscopies: Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed. For example, a visit on the same day could be properly billed in addition to suturing a scalp wound if a full neurological examination is made for a patient with head trauma. Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status
9 Coding Tips for Urology Modifier 25 for Medicare Per Medicare Claims Processing Manual (100 04) Section 40.1 (C) Minor Surgeries and Endoscopies: Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed. For example, a visit on the same day could be properly billed in addition to cystoscopy if a full urological examination is made for a patient with hematuria. Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status
10 Office Urology Coding Update Office E/M and Cystoscopy EOB Diagnosis: Gross Hematuria (599.71) (R31.0) E/M office visit with modifier 25 Urinalysis without microscopic examination Cystoscopy
11 Coding Tips Modifier 25 Do not use for a chief complaint: patient here for cystoscopy... or patient here for a urodynamic study With these chief complaints an auditor will never allow payments for an additional E/M service Bill an E/M service if it is not related to the decision for surgery Bill an E/M service if a visit is medically reasonable and necessary in the further care of the patient irrespective of the minor surgery performed 2013 NCCI Manual: Chapter 1
12 Modifier 25 in Urology Modifier 25 and E/M denials In 2014 there will be more and more carriers (Medicare, Geisinger, First Priority Health, Elderplan, Aetna, Avmed ) who will not reimburse for any E/M service on the same day as a procedure even with modifier 25 and separate diagnoses. All appeals will be unsuccessful try modifier 57
13 Errors in use of Modifier 59 Unbundling a CCI Edit Distinct Procedural Service Used to report for payment a bundled procedure performed on the same day as a primary procedure: Criteria to be met: Different session Different patient encounter Different procedure Different surgical incisions Different sites, separate organs Separate sites in a single organ Different organ system
14 2013/2014 Modifier 59 Medicare has stated that modifier 59 is appropriate...on a bundled procedure for payment if procedures are performed for lesions anatomically separate from one another.. in the same organ Findings: Stone in renal pelvis and upper pole calyx of the same kidney CPT ICD Ray Painter, MD & Mark Painter, PRS CEO, Urology Times, January 2013
15 Modifiers in Urology Modifier 76 Modifier 76 Repeat procedure or services by the same surgeon (during the same day or same time as an initial procedure)
16 2014 Modifier 59 Findings: left renal pelvic calculus and left ureteral calculus Procedure: ESWL for both calculi CPT Diagnosis
17 2013/2014 Modifier 59 Findings: left renal pelvic tumor and left ureteral tumor Procedure: Ureteroscopic biopsy of both tumors CPT Diagnosis
18 United HealthCare EOB Payment is made for both procedures performed in one kidney
19 52353 and Reimbursement Controversy AUA does not sanction this coding Many carriers (Medicare, commercial, and private) do not reimburse for the second or third procedures billed NCCI consider this inappropriate coding Many carriers do pay!
20 Medicare* now wants you to use modifier 76 alone for repeat exact duplicate services on the same day As of July 1, 2013 modifier 59 ( for a distinct service) is no longer considered a valid repeat modifier. Procedures billed with modifier 59 will be denied as exact duplicates. To avoid these denials on repeat same exact procedures, you may bill using only a 76 modifier (repeat service) Claim Example: Date CPT ICD 9 7/1/ /1/ *Part B News, September 16, 2013 Vol. 27, Issue 35; *NSG announcement:
21 For Medicare Use Modifier 76 in place of Modifier 59 Findings: Stone in renal pelvis and upper pole calyx of the same kidney CPT ICD
22 For Medicare Use Modifier 76 in place of Modifier 59 Findings: left renal pelvic calculus and left ureteral calculus Procedure: ESWL for both calculi CPT Diagnosis* *Diagnoses are never used to determine appropriateness of CPT codes or CPT compliance
23 Use Modifier 59 and 76 Different procedures in the same organ Findings: left renal pelvic calculus and left ureteral calculus Procedure: ESWL of pelvic calculus and Ureteroscopic fragmentation of ureteral calculus CPT Diagnosis* *Diagnoses are never used to determine appropriateness of CPT codes or compliance
24 Summary: Use of 59 and 76 Coding for Multiple Procedures in One Organ Medicare Modifier on 2 nd codes Duplicate exact CPT codes 76 Different CPT codes 59 and 76 Non Medicare Duplicate exact CPT codes 59 and 76 Different CPT codes 59 and 76 (Check: whether Non Medicare carriers follow Medicare rules)
25 Coding Errors for Treatment of Bladder Neck Contracture Correct Coding is Based on Etiology in the Male Congenital: ICD 9 Cystoscopic Incision , [Q64.31] Benign Hypertrophy (BPH): ICD [N32.0] TUIP TUIBN TURBN 52500
26 Coding Errors for Treatment of Bladder Neck Contracture Correct Coding is Based on Etiology in the Male Postoperative Bladder Neck Contracture: TURBN TUIBN (post radical prostatectomy)) (ICD ) [N99.111] Laser ablation of bladder neck contracture 52214
27 Catheterization Coding Errors Complicated Catheterization Use Complicated Catheterization for: Catheter passed over a guide wire Catheter guide Council tipped catheter Coude catheter Several catheters tried Instillation of lubricant into the urethra Difficult catheter removal (and replacement) Diagnoses: 598.9, N 599.4, 596.0, , V53.6 N35.9,N36.5, N32.0, T83.018A
28 52204 vs Biopsy of lesion Any size, normal mucosa Fulgurate bleeder from biopsy site Not a treatment $349.91/$142.13* Removal of lesion 0.5cm. or less Fulgurate the complete lesion or residual of the lesion/base Treatment of lesion $644.82/$205.98* *2014 Utah Medicare fee schedule
29 52204 and Cystoscopy/Biopsy vs TUR of Bladder Tumor Cannot be billed together (always bundled) Cystoscopy and biopsy alone or Cystoscopy, biopsy, and treatment of a bladder lesion, < 0.5 cm
30 Correct Measuring for Lesion Removal What to Measure for Skin Excisions ($150.42/$109.27) ($342.97/$273.28) margin (2.0cm) 1.0 cm. lesion Excised diameter = (lesion + 2x smallest margin): 1.0cm+4.0cm= 5.0cm margin (2.0cm) Measurement of lesion plus margins should be made prior to excision Includes a simple (one layered closure) when performed also includes administration of local anesthesia
31 Skin Closures Intermediate Closure: requires layered closure, deeper layers of SC and non muscle fascia as well as skin closure to Complex Closure: more than a layered closure with scar revision, debridement, extensive undermining, or retention sutures to Remember to code for both excision of the lesion and an intermediate or complex closure when performed; check: some bundling of lesion excision and repair codes will require modifier 59
32 Skin Lesion Excision and Skin Closure adjacent tissue transfer or re arrangement genitalia; defect 10 sq cm or less includes excision of lesions
33 14040
34 14040
35 Coding Questions now?? Or Call Me Later I d be Happy to Help! Private Cellular Office Fax E mail [email protected]
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